Provider Demographics
NPI:1053372177
Name:REDDY, NAGENDRA PRASAD (MD)
Entity type:Individual
Prefix:
First Name:NAGENDRA
Middle Name:PRASAD
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9677
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-9677
Mailing Address - Country:US
Mailing Address - Phone:866-500-7071
Mailing Address - Fax:866-500-7081
Practice Address - Street 1:894 E 3900 S
Practice Address - Street 2:#B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2151
Practice Address - Country:US
Practice Address - Phone:866-500-7071
Practice Address - Fax:866-500-7081
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005020847207R00000X
UT6369024-1205208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6369024-1205OtherUTAH DOPL
UT6369024-8905OtherUTAH DOPL CS
MO208331801Medicaid
UT000060550Medicare PIN
UT6369024-1205OtherUTAH DOPL
MO208331801Medicaid
UTI02492Medicare UPIN